Recently, I had the poor fortune of resuscitating a relatively young (in the late 40s) person who had a cardiac arrest enroute to the hospital. Patient was started on mechanical CPR with the LUCAS device and 1 shot of IV adrenaline was given pre-hospital. The initial rhythm was supposedly PEA, and the patient had chest pain and diaphoresis before collapse.
Upon arrival at the ED, it was about 10 minutes into the cardiac arrest. Mechanical CPR (mCPR) was continued and we achieved ROSC about 15 minutes post-arrest. The 12 lead ECG showed anterior STEMI. However, patient promptly went into PEA again and mCPR was resumed. Another shot of adrenaline was given and very soon, patient had a pulse. This was not sustainable and patient went into cardiac arrest again. Patient's pulse would come back after a good short period of CPR and adrenaline, but it was always non-sustainable. By now, patient was already on a adrenaline and noradrenaline infusion, in addition to controlled fluid boluses. There were no VF or pulseless VT encountered, so we did not give amiodarone, lidocaine, nor atropine, nor bicarbonate. At around 20 minutes post-arrest, I decided to give IV thrombolysis with rTPA. However, we could not administer the bolus IV rTPA until about 30 minutes post-arrest. By this time, the patient was in the 4th episode of cardiac arrest and mCPR continued in the face of thrombolytic infusion.
Despite 60 minutes of good quality resuscitation from the point of arrest, this patient did not survive. Would I give rTPA again, for similar cases? For PEA/asystole - I WOULD NOT. For refractory VF, I'm not so sure yet - but probably NOT. If strongly suspect PE - I would probably give.
Success with thrombolysis in cardiac arrest have been reported, but the data remained in case reports and retrospective series. A large randomized controlled trial (TROICA) published in NEJM in 2008 showed NO DIFFERENCE in witnessed out-of-hospital cardiac arrest patients who received tenecteplase or placebo during cardiopulmonary resuscitation.
Böttiger et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 2008, Dec 18;359(25):2651-62.
A good commentary on the above study can be found in the journal Crit Care.
So, what can we do with STEMI patients who want to remain in cardiac arrest? Apparently, sending them to the cath lab while undergoing mCPR is a viable solution. Dr Stephen Smith has a good writeup on this issue in a recent post. It is possible to bring a patient to the cath lab while undergoing CPR with the LUCAS device. (I initially thought that was a no go because the device would not allow the image intensifiers to work). However, the promising article described patients who arrest in the cath lab, not out-of-hospital. For refractory VF, I am thinking of IV esmolol boluses instead, in addition to traditional therapy (also see here).
I don't think we can bring a patient with mCPR to the cath lab in our setting. Until the day ECLS with eCPR arrives, we can only keep our fingers crossed for such patients.